With Robert Gregory
In State Farm Mutual Automobile Ins. Co. v. All Family Clinic of Daytona Beach, Inc., the circuit court in Volusia County ruled that an insurance carrier does not waive defenses related to reasonableness of charges by utilizing an auto-pay process when issuing payment.
The case involved a November 12, 2012, bill from All Family for MRI services. Payment was issued by State Farm on December 4, 2012, noting that the payment was based on a reasonable under the terms and conditions of the policy, as well as, Florida Statute 627.736(5)(a)(1). This payment was issued using the “auto process tool,” or “auto-pay system” implemented by State Farm. All Family filed suit over the remaining balance.
In the underlying action, All Family moved for summary disposition arguing that placing the bill into the auto-pay system was evidence of a waiver of State Farm’s 30-day statutory right to investigate whether the medical service was reasonable, related, and/or necessary. The trial court agreed with All Family finding that by placing the bill into an auto-pay system State Farm knowingly and voluntarily waived its right to investigate the MRI bill, thus State Farm was prohibited from challenging the bill as being unreasonable, unnecessary or unrelated.
On appeal, the court found that Florida Statute Section 627.736(4)(b)(6) allows an insurer to dispute the reasonableness of charges at any time, including after payment of the claim or after the 30-day period for payment.
Under 627.736(4)(b)(6), an insurer retains the ability to defend a lawsuit initiated by a medical provider seeking additional payment on the grounds that the service was not medically necessary or that the amount was not reasonable even if the provider’s claim had previously been reduced. Northwoods Sports Medicine and Physical Rehabilitation, Inc. v. State Farm Mutual Automobile Insurance Company, 137 So. 3d 1049, 1057 (Fla. 4th DCA 2014), citing United Automobile Insurance Company v. Rodriguez, 808 So. 2d 82, 87 (Fla. 2001) (holding that insurer’s failure to pay PIP benefits within the 30-day statutory period does not forever bar it from contesting the claim).